2013 AAFP Town Hall

Defining, Defending Family Medicine's Scope of Practice

September 24, 2013 07:15 pm Matt Brown San Diego –

Defending the scope of family medicine and preserving its comprehensive nature well into the future were the main threads of conversation that wove through much of the evening during the 2013 Town Hall meeting at the Congress of Delegates here on Sept. 22.

Reid Blackwelder, M.D., of Kingsport, Tenn., notes that focusing on the "truths" that exist across regional and state boundaries is the key to unraveling scope-of-practice issues facing family medicine.

AAFP President Jeffrey Cain, M.D., of Denver; Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash.; President-elect Reid Blackwelder, M.D., of Kingsport, Tenn.; Speaker John Meigs Jr., M.D., of Brent, Ala.; and EVP Douglas Henley, M.D., of Leawood, Kan., kicked off the meeting with a series of reports, including presentations on scope of practice and the upcoming Future of Family Medicine project

Physician, Define Thyself

According to Blackwelder, how the Academy defines primary care will be a critical issue going forward. He said one of the key components to the discussion is recognizing the significant difference between primary care services -- which myriad different specialties can perform -- and actual, comprehensive primary care.

Story Highlights
  • AAFP leaders and members discussed the future of family medicine scope of practice and the importance of defining primary care during the recent Town Hall meeting in San Diego.
  • Members noted that patient needs should be the final determining factor in defining the primary care team.
  • Family physicians ultimately can solve scope-of-practice issues by recognizing the power of the team in caring for patients, said AAFP President-elect Reid Blackwelder, M.D.

"That distinction is extremely important, and one of my challenges (as president) is to first recognize that people have strong emotions (about scope of practice), but also recognize how we need to talk about certain aspects of this issue with legislators because it is very much a state-by-state issue," Blackwelder said. "There is not an easily found national or global solution because of those variables that exist in each state."

The key, Blackwelder said, will be focusing on the "truths" that exist across regional and state boundaries. For example, he said, "No one has your education and training. Even without experience, you have 21,000 hours (of training) … and it doesn't matter what school or what residency (you attended), we know where (family physicians) are starting from."

On the other hand, said Blackwelder, education and certification expectations for nurse practitioners (NPs) are not standardized and can vary from state to state. "It can be anywhere from 3,000 to 6,500 hours, and that's not good or bad, it's just the truth," he said, noting that training hours don't vary for family physicians.

Oregon state senator and alternate delegate Elizabeth Steiner Hayward, M.D., said she believes that focusing on what NPs should and should not be able to do is the wrong approach. Instead, she said, family physicians must use these opportunities to figure out what is best for patients going forward and to negotiate better to get the assurances for which family medicine is looking.

Oregon state senator and alternate delegate Elizabeth Steiner Hayward, M.D., asks family physicians to rethink how they approach the scope-of-practice issue.

"As Glen (Stream) pointed out, in Texas, CRNAs (certified registered nurse anesthetists) wanted prescribing privileges and the anesthesiologists were against that, but many of our members in rural areas only have CRNAs to work with," said Steiner Hayward. "So we have to think about scope of practice not as this monolithic thing, but as what is best for our patients and what's going to help us practice the kind of medicine that we know we can do to provide the best care. So, I just want to encourage the Board of Directors and everyone else to really rethink how we talk about scope-of-practice."

Blackwelder said the AAFP -- and the family physicians the Academy represents -- ultimately can solve scope-of-practice issues by recognizing the power of the team in caring for patients.

"That is all of us; everybody that is part of the team in your community or your individual practice is part of the answer," he said. "It is a lot more fun to frame this as a battle or 'right vs. wrong,' and that is not really the case at all. We are all working in this together, and we each have the ability to be a part of the solution."

Comprehensive Issue

Special constituency delegate Marie-Elizabeth Ramas, M.D., a new physician currently working in a rural California practice and successfully offering full-service care to her patients, expressed concern regarding the narrowing of focus she said she hears the leaders from both the AAFP and American Board of Family Medicine talking about, particularly as it applies to obstetrics and various surgical specialties.

Special constituency delegate Marie-Elizabeth Ramas, M.D., expresses concern about the perceived notion that family medicine is narrowing its focus.

Ramas said she perceives that family medicine residents entering her community lack the breadth of ability needed to offer the kind of comprehensive care small towns require, and she asked how the AAFP is branding its scope and level of specialty to both medical students and the general public to set family medicine apart.

"I am encouraged that we are now putting value in that (full-service, comprehensive image), and now I would love to see the Academy catapult that image -- that brand of what family medicine really is -- so that my generation of family medicine residents and students can have something to be proud of, rather than something to work into," said Ramas.

In response, Stream assured Ramas of the Board's deep concern regarding family physicians narrowing their scope of practice. "Very clearly, the value (FPs) bring to the health care system is through comprehensive primary care practice," he said. "Being the gatekeeper to the rest of the health care system is not how we provide that value."

The Future of Family Medicine

When asked to define the greatest challenges facing family medicine, EVP Henley pointed to family medicine's ability to demonstrate that it is offering both improved quality and cost efficiency in care at the practice level and for populations of patients.

AAFP COD is Online

Don't forget to follow the business sessions of the AAFP's Congress of Delegates via live streaming video(www.ustream.tv). The final business session of the COD convenes on Wednesday, Sept. 25 at 9 a.m. PDT. For those who missed out, you can view archived versions of the COD's business sessions soon.

Also be sure and catch all the social media chatter at the COD via a daily synopsis of tweets and photos(storify.com) put together by AAFP staff members.

"How are family physicians going to demonstrate how to bend the cost curve and increase the level of quality at the population level?" Henley asked. "That will be the biggest challenge (facing family medicine and the Academy), and it will drive payment the next 5 years."

A more comprehensive answer to that question, Henley said, will come at the 2014 Scientific Assembly in Washington, by which time the AAFP's Family Medicine Working Party will have published its updated findings on the tentatively titled "Family Medicine for America's Health: Future of Family Medicine 2.0" project.

"It's an opportunity for us to continue to be proactive rather than reactive in terms of changing the health care system in positive way, as well as identify the changes we need to make in the discipline to affect that and deliver on the triple aim of delivering better health, better care, at lower cost," he said. "Separate from that is the challenge to the Academy regarding how we recognize the various member segments that we have and serve their diverse needs."


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